Basic Information
| Provider Information | |||||||||
| NPI: | 1477667244 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PLATTE RIVER MEDICAL CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2801 PURCELL ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806013551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036597600 | ||||||||
| FaxNumber: | 3035588223 | ||||||||
| Practice Location | |||||||||
| Address1: | 2801 PURCELL ST | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | CO | ||||||||
| PostalCode: | 806013551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3036597600 | ||||||||
| FaxNumber: | 3035588223 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 05/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | EUSER | ||||||||
| AuthorizedOfficialFirstName: | ELLEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING | ||||||||
| AuthorizedOfficialTelephone: | 3036597600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 95158260 | 05 | CO | MEDICAID |